Synopsis The CHARLOTTE EXPLORER4 (CE4) and its two occupants were declared overdue when the small boat did not return to the mother ship CHARLOTTE EXPLORER on the evening of 12September 1995. A search initiated by the crew of the mother ship using other small craft continued throughout the night. At dawn, more boats and a helicopter joined the search. The CE4 was found upside down on a beach on the north-west corner of Hippa Island. Soon afterward, the crew of the helicopter sighted the bodies of the small boat's two occupants in a kelp bed just off the coast. The Board determined that the chartered CE4, while fishing alone with the outboard motor most likely stopped, capsized after drifting into an area of kelp and rocks where a combination of tide and sea swell was locally creating large waves of up to, or larger than, seven metres with breaking crests. The charter company's procedures with regard to fishing alone, maintaining regular radio contact and patrols to ensure the safety of its guests were not enforced. There was delay in determining that the small boat was overdue and in starting a search. As there was no witness, the exact location, time and cause of the capsizing could not be determined. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessels The CHARLOTTE EXPLORER4 (CE4) is an aluminium open boat with two midships consoles, powered by an outboard motor controlled and steered from the starboard console. The hull is of shallow-vee, single-chine form and incorporates a sealed double-bottom, bow and stern buoyancy compartments (see AppendixE, Photograph1). There is a storage compartment in the bow, with a door, where the lifejackets are stowed. Abaft the bow compartment is a fish bin for storing the catch, which has separate self-draining holes. The cockpit is also self-draining through drains in each aft quarter. The CHARLOTTE EXPLORER is a converted seismic vessel with the wheel-house forward. The accommodation runs the full length of the main deck and the forward two thirds of the upper deck. The after part of the upper deck is open and used for storing the small boats during transit to and from the Queen Charlotte Islands. When on station in the Queen Charlottes, the vessel acts as the mother ship for 18 small aluminium open boats and as a hotel for the guests. 1.2 History of the Voyage Tuesday, 12September 1995, was the penultimate day of the vessel's fishing season before the CHARLOTTE EXPLORER returned to her winter berth in Vancouver, B.C. Two guests, a man and a woman both 76 years old, departed the CHARLOTTE EXPLORER between 0700(3) and 0730 on board the CE4 which had been assigned to them for the duration of their fishing trip. By means of the boat's very high frequency (VHF) radio, they made radio contact with the morning fish master on channel 69. They then proceeded from the anchorage in Nesto Inlet to the north-western side of Hippa Island, where they were seen fishing off the kelp beds during the morning. There were eight small boats with guests and one small boat with crew aboard out on the water. Seven of the remaining small boats had been stripped ready for the return to Vancouver. The morning fish master, who patrols the fishing areas and assists the guests as required, saw the CE4 among a group fishing on the south side of the north-west corner of Hippa Island. After the fish master saw the CE4 and spoke to its occupants by radio around noon, no one recalls seeing it again. During the morning, the morning fish master noted that the tide was tending to push the boats away from the island. He also noted that there were breakers of up to seven metres in height in the vicinity of the north-west tip of Hippa Island. He expected the tide to turn and start pushing the boats toward the island after lunch. He went off duty at 1300, and was relieved by the afternoon fish master. The custom aboard the CHARLOTTE EXPLORER was to keep a tight check on the whereabouts of guests in inclement weather. As the weather was good on the day of the occurrence, the afternoon fish master did not get a complete hand-over briefing. When he and a guest left the CHARLOTTE EXPLORER on his boat, there were three guest boats at the dock. He did not carry out a complete check of the other boats by radio, but went out to patrol and fish with the guest. He headed out of the west entrance of Hippa Passage and around the north of Hippa Island, to where the morning fish master had said the guest boats were fishing. When he arrived off the lighthouse point of Hippa Island, there were no guest boats there. He remained at the point and fished outside the kelp. The afternoon fish master spoke to some of the guests by radio during the afternoon, but not with the occupants of the CE4. It was only when he moved down to the south end of HippaPassage to fish, at about 1600, that the fish master first sighted one of the other boats (the CHARLOTTE EXPLORER12). It was at the south-west corner of Hippa Island; there were fiveother boats in the area as well. At approximately 1730, the afternoon fish master received a radio message that a crew boat that was fishing at the south pass was returning to the mother ship. At this time, he thought all the boats were accounted for, with five guest boats fishing around the south pass and the three guest boats that were at the ship when he left earlier. He assumed that these three guest boats were still at the ship as he had received no radio message indicating that any had returned to the fishing grounds during the afternoon. The afternoon fish master fished with the guest until 1800 or 1830 and then returned to the CHARLOTTE EXPLORER via the southern entrance to Hippa Passage. During his return, he saw five boats, three in the southern passage and two on the north side of the island. Upon entering Nesto Inlet, he saw several boats clustered together at the head of the inlet while the occupants watched a bear and cubs on shore. One of the boats had grounded on the falling tide, and the fish master unsuccessfully tried to tow it off. Leaving the grounded boat to be dealt with later, he took its occupants on board his boat and returned them to the mother ship. After returning to the CHARLOTTE EXPLORER at approximately 2015, he did a boat count and discovered that one boat (the CE4) was missing. The afternoon fish master notified the morning fish master that a boat was missing, then took his boat back out to Marchand Point in Hippa Passage to try to contact the CE4 by VHF radio. There are several localized radio reception problem areas; the mother ship could not always reach the boats out on the water. Depending on their location, the fish masters on patrol outside Nesto Inlet often could make radio contact even with the much smaller sets in their boat. When the fish master received no reply from the missing boat, he notified the corporate representative, who is the liaison between the guests, the ship's master, the fish masters and the vessel's crew. A search was commenced at 2035. The search, under the direction of the corporate representative and the master, continued throughout the night until the missing boat was sighted on a beach at 0800 on 13September 1995. 1.3 Injuries to Persons Autopsies determined that the cause of death of both occupants of the CE4 was by drowning. 1.4 Search and Rescue Operation The crew of the CHARLOTTE EXPLORER commenced the search at 2035 on 12September 1995, after the afternoon fish master had tried unsuccessfully to make radio contact with the CE4, from outside the entrance to Nesto Inlet. At 2035, three boats operated by crew from the CHARLOTTE EXPLORER were dispatched to different locations to search: one to Skelu Bay, a second to Athlow Bay, and the third to the west side of Hippa Island. The search areas were based on information other guests on the CHARLOTTE EXPLORER had given the corporate representative, that the CE4 guests had said the previous evening they were going to try Athlow Bay. No one involved in the initial search was aware that the morning fish master had seen the CE4 at the lighthouse point on Hippa Island at noon. The boats completed this initial search at 2330. As nothing was found, the master informed Prince Rupert Coast Guard Radio Station (CGRS) of the situation at that time. The CGRS made a Marine Information Broadcast (MIB) requesting vessels in the area to keep a look-out for the missing boat. It also contacted the Rescue Co-ordination Centre (RCC) in Esquimalt, B.C., to initiate the search and rescue (SAR) response. The crew of the CHARLOTTE EXPLORER continued the search in the vessel's boats throughout the night. The master contacted two local airline companies to order a helicopter and a fixed-wing aircraft to assist with the search after dawn. Meanwhile, RCC Esquimalt arranged for a Buffalo aircraft to fly to the scene and for a Canadian Coast Guard (CCG) Sikorsky helicopter to leave Prince Rupert, B.C., at dawn to aid in the search. At 0640 on 13September, the Buffalo was in Sandspit, B.C., refuelling for the search, and at 0650, the search areas for the boats were determined in consultation between the helicopters and the CHARLOTTE EXPLORER. The boats, including several operated by guests, left the mother ship at 0720, and all were on station ready to start searching by 0745. At 0755, the morning fish master saw an overturned boat ashore, at the north-west end of HippaIsland, just south of the lighthouse. By 0810, he had confirmed that the overturned boat was the CE4; the search for persons in the water continued. Two people from the CHARLOTTE EXPLORER were landed and conducted a shoreline search in both directions from the stranded boat. More people from the mother ship landed and began the work of recovering the boat. The Buffalo aircraft, the Sikorsky helicopter and the boats continued searching. At 1015, a body was sighted in the kelp approximately 250 metres west-south-west of the stranded boat, and at 1045, a second body was sighted nearby in the same kelp bed. Crew boats retrieved both bodies. Both victims were wearing Mustang Type 1800, fisherman's marine anti-exposure and flotation suits, consisting of a jacket and high-bib trousers. To provide extra support, the Mustang suit has an inflatable collar which the wearer can inflate by blowing into a tube. The man had not inflated the collar on his suit. The woman had managed to inflate her collar partially, approximately 15percent by volume (see AppendixE, Photograph2), but not enough to make a significant difference to her support in the water. Both victims had either lost or shed their rubber boots while in the water. After recovering the bodies, it was noticed that several pieces of equipment from the boat were in the water between the beach where the boat was found and the location of the victims'bodies. 1.5 Damage to the Boat The CE4 was found on the beach extensively damaged. (See also Section 1.11.) 1.6 Location of the Boat's Equipment Some of the loose equipment was seen in the kelp bed offshore from the beach where the boat was discovered. One of the pieces of equipment found was a halibut harpoon and its plasticfloat. 1.7 Certification The CE4 has a Transport Canada Small Craft Decal and has type approval. The CHARLOTTE EXPLORER was certificated in accordance with the Canada Shipping Act for the trade in which she was engaged and for the area of operations. 1.8 Personnel History 1.8.1 Guests Both guests were elderly American citizens. The man had many years' experience of sport sea fishing and had enjoyed a successful fishing trip to the Queen Charlotte Islands the previous year on the CHARLOTTE EXPLORER. It was reported, however, that while his fishing experience was great, his experience of small boat handling was limited. The woman, a long-time friend of the man, had little or no experience of sea fishing and no boat handling experience at all. 1.8.2 Officers and Crew Members The master of the CHARLOTTE EXPLORER holds a Canadian Master Mariner's Certificate. He has been the master of the vessel for four years, engaged in the same trade. The morning fish master has been so employed for four years. Prior to this, he was a deck-hand for three years. He has no marine certificates, nor are such certificates required for the duties he performed. The afternoon fish master has four years' experience as a commercial fisherman and a further four years as a sport fishing guide. He had joined the CHARLOTTE EXPLORER as a fish master two years earlier. He has no marine certificates, nor are such certificates required for the duties he performed. The corporate representative is the president of the company, which he represents during his tours of duty on board the CHARLOTTE EXPLORER. He has 40 years' experience in marina and tourist operations within his family business, of which this operation is a part. He has no formal marine certificates, nor are such certificates required for the duties he performed. 1.9 Weather and Tidal Information Environment Canada has two recording stations in the area. The Kindakun Rocks weather station is 15 miles SSE of Hippa Light and the West Moresby buoy is 63 miles south of HippaLight. The Kindakun Rocks station is equipped to record air temperature and pressure, as well as wind speed and direction, while the West Moresby buoy is equipped to record air temperature, wave height, wave period, maximum wave height, wind direction, wind speed and wind gusts. Hippa Island, Kindakun Rocks and West Moresby buoy generally all experience the same weather as they are all open to the Pacific Ocean. On 12September 1995, for the period 0628 to 2328, Kindakun Rocks recorded air temperatures between 13 and 15C and wind speeds between two and nine knots generally from the north or north-west. For the same time period, the buoy at West Moresby recorded air temperatures ranging from 15to 16C, with winds from 4 to 10 knots generally from the north or north-west. The wave heights were between 2 and 3.6m, with maximum waves peaking at 7m at 1335. The wave periods were in excess of 11 seconds, indicating that the waves were ocean swells. Wind-generated waves in the area have a period of between four and nine seconds. The tides at Port Louis, 10 miles north of Hippa Island, and referenced on Tofino, on 12September 1995, were predicted to be 1.188m above chart datum at 1008, and 3.993m at1607. The Sailing Directions for the British Columbia Coast (North Portion) note that: Foul ground surrounds Hippa Island. Quequitz Reefs, an area of drying and sunken rocks, are west of HippaIsland and a shoal finger extends NW from the islets off the NW end of the island. 1.10 Stability of the Boat The CE4 is designed to be very stable. One of the owners' requirements was that, in moderate weather, three people could stand on one side of the boat and haul a 90- to 120-kilogram halibut aboard, without immersing the gunwale. 1.11 Condition of the Boat after Recovery Inspection of the CE4 on the beach revealed that both consoles had been ripped off. These were also found ashore, nearby. Both seats behind the consoles were badly damaged. The outboard motor cover was missing; it was not recovered. At the top of the outboard motor, the flywheel and starter ring gear were damaged (see AppendixE, Photograph8). The motor was switched off, the gear lever was in the neutral position, and there was no indication that the propeller had been fouled by kelp. The bottom of the boat (see AppendixE, Photographs3 and 4) showed no signs of grounding damage. Both lifejackets were found, stowed in the bow locker (see AppendixE, Photograph5), but all loose gear was missing from the boat. Some of this gear was found between the location of the victims' bodies and that of the stranded boat. The VHF radio was still in place in one of the consoles, switched on and tuned to the frequency used for communication, VHF channel 69. Some time prior to this accident, the integrity of the starboard aft buoyancy tank built into the transom of the boat had been breached in order to feed a new steering control cable through the body of the tank. Ideally, this cable should have been fed through the pipe fitted for that purpose (see AppendixE, Photograph6). 1.12 Responsibilities and Duties of the Crew of the CHARLOTTEEXPLORER The master has overall responsibility for the vessel and the small boats used by the guests. During the day, he maintains a radio listening watch and supervises the crew on board thevessel. The corporate representative is responsible for the co-ordination between the CHARLOTTEEXPLORER and guest fishing activities. He spends some time out on the water and some time on board the mother ship. The fish masters are required to ensure the safety of all guests, to scout fish locations, to experiment with new techniques, and to lend assistance to individual guests requiring help catching or landing big fish. Corporate literature indicates that the safety of guests is the fish masters' paramount duty. The back-deck crewmen keep the boats refuelled and re-supplied with bait when the guests are back on board. They meet the guests and prepare the fish caught for shipping when the guests depart for home. They normally see the guests off when they go fishing. 1.13 Operation of the CHARLOTTE EXPLORER and the Small Boats During Guest Fishing Activities The CHARLOTTE EXPLORER is moored, perpendicular to the beach, with two bow anchors out and stern lines to the beach on the south side of Nesto Inlet. A floating dock is constructed alongside the vessel. The small boats are tied up to the floating dock when they are not beingused. During the night, engineers check the boats' outboard motors and radios. The night back-deck crewman checks each boat to ensure that it is ready for the next day and stocked with fishing gear, bait and fuel. In the early morning, at a time that they choose, guests depart in their boat to fish. There is no time set to return to the mother ship. The back-deck crewman asks guests to check in by radio but not all of them do so. While out on the water, the guests are requested to buddy-up with another boat and to contact the fish master by radio to advise of their whereabouts during the day. The morning fish master departs at daylight and stays out until approximately 1300 when he hands over to the afternoon fish master who stays out until sunset. During the day, the fish masters patrol the area, talk to guests by radio and assist them when necessary. There is no scheduled radio reporting regime in place for boats to report their whereabouts. Both fish masters use the same boat and equipment; normally only one is on the water at a time. When guests return to the mother ship, they hand over their catch to the back-deck crewman on duty for processing. They may also arrange with him to have photographs taken with bigfish. 1.14 Information Provided to the Guests on Safety, Boat Operation and the Area 1.14.1 Before Boarding the CHARLOTTE EXPLORER During the fishing season, guests are flown in from Vancouver to Nesto Inlet on a twice-weekly basis. On the flight to the Queen Charlotte Islands, all guests are given a small information booklet to read. It deals, in brief, with such topics as what to do When You Arrive, Your Boats, various fishing topics, Safety First!!!, Fish Master's Role, and various items about the catch and the crew's role. (See AppendixB.) The booklet stresses the remoteness of the area, the rapidity of change in the weather, the importance of the buddy system and of keeping in radio contact if fishing alone. 1.14.2 On Board the CHARLOTTE EXPLORER The guests are assembled in the upper lounge and are given a three-part introduction into the arrangements on board the CHARLOTTE EXPLORER, and fishing techniques and areas. They then don Mustang 1800 suits and are given a practical demonstration of the small boats they will be using. Each boat is assigned to a particular group of fishers for the duration of their stay. All 16 boats are then taken, together, for a test run in Nesto Inlet. During this test run, at least three people from the company are with the guests to observe and assess their boat handling capability and to identify those guests who require more training. Guests who are identified as requiring more hands-on training in boat operation are given such training before they are allowed to go out on their own. 1.14.3 In the Small Boats On board every boat, there is a plasticized information book entitled Your On the Water Companion (see AppendixC). The centre pages are reduced copies of the Canadian charts of the area. One of these is chart No.3860, Hippa Island section, and the other is a section of chart No.3869 showing the west coast of Graham Island from Hosu Cove to Seal Point and includes Hippa Island. The book gives the location of the boat's safety equipment and advises guests to familiarize themselves with it. The fact that the boats operate in a remote area is again pointed out as is the advantage of the buddy system. The importance of maintaining radio contact, the observance of good seamanship and of personal responsibility are stressed. 1.14.4 Notices Attached to the Boat Attached to the CE4 in prominent places are clear and legible notices in black print on a white background. These notices reiterate The Boater's Responsibility Code and Safety, give advice on seamanship, instructions for the proper use of the radio, starting instructions for the motor, and indicate the stowage of life-saving equipment. 1.15 Charter Vessel Operation and Regulations The vessel was operating as a mother ship or lodge for small boat private fishing trips and was secured to the beach. As such, she did not require a full marine complement. Most vessels reduce the number of deck crew in favour of persons working to maintain the small boats and to clean and pack the fish caught by the fee-paying guests. There are no regulations governing the operations of small charter vessels once the mother ship is secured in her seasonal position. The industry is self-monitoring. The small boats have to comply with the Small Vessel Regulations made pursuant to the CanadaShipping Act regarding the equipment which must be carried on board. The CE4 was fully and properly equipped. Guests are not required by the operators of the mother ship to have a current radio licence, even though most of the boats in use are fitted with radios which the guests are expected and encouraged to use for safety communications and to maintain contact with other boats and the mother ship. Guests are not required to report medical conditions or navigational skills before arrival on site. One or two fish masters are normally employed to look after the guests, but the guests are allowed to take out small boats without direct supervision of their activities or whereabouts.